HomeMy WebLinkAboutMiscellaneous - 220 CANDLESTICK ROAD 4/30/2018 / 220 CANDLESTICK ROAD
210/106.A-0198-0000.0
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t NORT1{
TOWN OF NORTH ANDOVER
PERMIT FOR WIRING
,SSACHUS�
This certifies that ............ ...... <..7�f 1..�.............................
has permission to perform .........�.' ?. ...... o ��. ...............................
wiring in the building of................ CA 0, .
at.............. .. x?etni 4(. .. ........... ,7th Andover,Mass.
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Fee.... Lic.No.lU9 df .............
ELECT ICAL INUMMR (/
Check #
t
Official Use Only
Permit No.
.uePar+I+nsnt o/�1ry �irvk�s
Occupancy and Fee Checked
BOARD OF FIRE PREVENTION REGULATIONS Rev. 1/071 leave blank
APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK
All work to be parlormod In aoomlanoo with Ow Massachusotu Eloctrical Code(Meg) 327 CMR 12.00
(PLEASE PRINT IN INK OR TYPE ALL INFORMATION) Date: %Z 1`f io
City or Town of: / boiw ,w To the lnspector (jV'ires:
By this application the undersigned gives notice o his or her intention to perform the electrical work described below
Location (Street & Number)' Z C-4,,D4—r-S774< eo
Owner or Tenant .SC1-6 :iezrD Telephone No.
Owner's Address
Is this permit in conjunction with a building permit? Yes ❑ No ❑ (Check Appropriate Box)
Purpose of Building Utility Authorization No.
Eii3dag Service Amps / Volts Overbead ❑ Uadgrd ❑ No. of Meters
New Service Amps / Volts Overbead ❑ Uodgrd ❑ No. of Meter-
Number of Feeders and Ampacily
Location and Nature of Proposed Eleelrical Work: /AIMaL� 4(')k 2
Com le Non of OwNtowing table=be waived by the Ins cror of Wvrs
f Tl
No. of Recessed Luminalros No.of Cell.-Susp.(Paddle)Faces 'T•raQsformers KVA
es
No. of Luminalre Ogtlets No.of Hot Tubs Ceneralors KVA 1
Abov n• o, o Emergency Lighting
No. of Luminaires Swimming Pool rind. ❑ rad. ❑ Battery Units
No. of Receptacle Outlets No.of OU Burners FIRE ALARMS No.of Zone
o
No. of Switcba No,of Cas Burners /
o. cec oaao
Initiatla Devices
No. of Ranges No.of Air Coad. Toonns No, of Alerting Devices
ump JAU oOf e - onta ne
T00;No. of Waste DlsP rs
Delectloa/Alerting Devices
Munical
No. of Disbwasbers Space/Arso Heating KW Lo�l❑ Connection C] Other
No. of Dryers Heating Applisaess . TC1V ecu Systems,
rY No.of Device or Equivalent
No. o Itero.o o.o Data Wiring:
• Hwters KW Signs Ballasts No. or Devlces or E uivaleni
dromaua c Batbtubs No.of Motors Total HP
Telecom Nor De cations trinee:
No. N
r e N0.Of vlces or E uivalcnt
OTHER:
Attach addlNona/detail((deiired or ar required by rhe Inspector o/Wirrs
Estimated Value of Electrical Work: (When.roquirod by municipal policy.)
Work to Start: Inspootions tq be requested in accordance with MEC Rule 10, and upon completion.
INSURANCE COVERAGE; Unless walvod by the owner,no permit for the performance of electrical work may issue unless
the licensee provides proof orllabillty Irtstuum inoWing"completed operation"coverage or iu substantial equivalent. The
undersigned cordfles that such ooverage U In foroe,and has exhibited proof of sure to the permit issuing office.
CHECK ONE: fNSURANCE a BOND ❑ .OTHER ❑ (Spoolfy:)
/cero, under the pains and penaXa ojpirlury,Mal the In(ormatlon on this appUeadon is true and eomplere, q
FIRM NAME: T i e.r II-t(A l-G: LIC. NO.: I `( I '0 3�
Licensee: DAQI D A(*4A2 Signature �— LIC. NO.: • ;
(If applicable, enter "exempt"In the lkvme number 1pwj, V Bus.Tel.
Address: .9"7 aero M oNT SM4 Alt.Tel. No.: 1113-7 S- '613
Per M.G.L.c, 147, s.57-61,security work roqulres Department of Public Safety"S"License: Lic. No.
OWNER'S INSURANCE WAIVER: I am aware-that the Licensee doer not have the liability insurance coverage normally
required by law. By my signature below, I hereby walye this requirement. I am the(check one)E) owner 0 owner's agent.
Owner/Agent PERMIT FEE' S
Signature Telephone No.
t
r '
y The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): _PM 1 O (=LCC- Z(L A1- (_O N T gA c-T 1)-4 G L L-C-
Address: 7 6ELN1oiJT S1-
City/State/Zip: NoRro Aiya, M4. ol6q 5 Phone#: q18 ' 02
Are you an employer?Check the appropriate box: Type of project(required):
4. I am a general contractor d
g ontract ran I
1.® I am a employer with � ❑ 6. E]New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. EJ Demolition i
and have workers' E
working for me in any capacity. employees E
9. F1 Building addition
[No workers' comp. insurance comp. insurance.$
!
required.] 5. ❑ We are a corporation and its I O.E2-Electrical repairs or additions i
3.El officers have exercised their 1 am a homeowner doing all work 1 I.❑ Plumbing repairs or additions
myself ' right of exemption per MGL
Y Mo workerscomp. 12.❑ Roof repairs
insurance required]t c. 152,§1(4),and we have no
employees. [No workers' 13.❑Other
comp. insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers compensation insuranceror my employees. Below is the policy andIob site
information.
Insurance Company Name: IAP OVE(Z Amepo cAt4
Policy#or Self-ins.Lic.#: w 2 tJ rj-D q O ! 7 2- Expiration Date: 3
Job Site Address: e/{��oCFC '� City/State/Zip: /'J
' Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DLA for insurance coverage verification.
i
I do hereby certify under t e pais snd aloes of perjury that the information provided above is true and correct
r--
Si ature: Date: 2-//V/,/,j
Phone#: 9'70 - �) e 2—6 ,2
Oficial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/ own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
75 1 Date./ . .. ....
NORTh
pf „ao ,ti°
of ' TOWN OF NORTH ANDOVER
' X PERMIT FOR GAS INSTALLATION
. 1a
�,SSACNUSEt
This certifies that . . � . . . . . . . . . . . ..
has permission for gas installation . . . 1,7. . . . . . . . . . . . . . . . . . . . .
in the buildings of . . .TG .F!r.
at . .2. f . . . . . . . . . . ,, North Andover, Mass.
Fee. . .- Lic. No..�?. / . . . .�!�` �.�,� . . . . . .
S-
INSPECTOR
Check# 2j )
f
MASSACHUSETTS UNIFORM APPLICATION FOR P WT TO DO GASFITTING
T i AP j-)1)j JU-D_ ,Mass. Date 20 /0 Permit# _
Building Location Owner's Name J� O 77e-L.,n
T ��Nle Li'ST I C. io h Type of Occupancy 1-S ice_
New ❑ Renovation ❑ R lacement g— Plans Submitted: Yes❑ No p—
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00 � c� aU > o
EA sN'
NT
T FLOOR
2NI FLOORR.1 `1 FLOOR' '4TII FLOOR1`H FL )OR1"11`l 1sL OR
S�V NTII 7TH FLOOR
1uoirrI1 8-ru)FLOOR
Installing Com any Name CA aA A-� Act-&-6
Address neLho Check one: Certificate
X . t dU
Business Telephone �0 C? ❑ Partnership
Name of Licensed Plumber or Gasfitter v I ❑ Finn/Co.
INSURANCE COVERAGE:
I have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL
Ch. 142 Yes ®r. No❑
If you have checked yes,please indicate the type of coverage by checking the appropriate box.
A liability insurance policy IT - Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER I am aware that the licensee does not have the insurance coverage required
by Chapter 142 of the MGL,and that my,signature on this permit application waives this requirement.
Signature of Owner or Owner's Agent Owner ❑ Agent ❑
I hereby certify that all of the details and information I have submitted(or entered)in above application are true
and accurate to the best of my knowledge and that all plumbing work and installations performed under the
permit issued for this application will be in compliance with all pertinent provisions of the achu��tts State
Gas Code and Chapter 142 of the General Laws.
By T}pe of License G
Title ,-Plumber ®—Master Sign 'LicensedPlumber/Gasftter
City/Town ❑ Gasfitter ❑ Journeyman License Number
APPROVED OFFICE USE ONLY)
N2 2311 ........
Date
HOR71,
°f<"`°:•�"° TOWN OF NORTH ANDOVER
p PERMIT FOR WIRING
�,SSACMUS�
�.. 5
This certifies that ...... .. ................f... .! ....... S
has permission to perform ......,,,r.�..�.q.a.m.......�i.�/
.... .....................
wiring p in the building of..`...P. �?..(Z............�-..c..�I A.�. e.�... ......................
at.....c�4Q....C. s^.G�i.�'�.5. �C{..�?..:......... ..... .North Andover, ass.
jr Fee J d Lic.No.I S�0 6 G .... ......... ......
..... . .... ............. ....... .... . .. .
J
ELECTRiCALINSPECTOR
� Check # ()
WHITE: Applicant CANARY: Building Dept. PINK:Treasurer
—y -CSA=;?=.` O FIRE P;:�E `.N s&N PEG1ULA i:C{N _..
r_ � u [tet• s G 1
�'•� 77 q ter- ^ p.�
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(P1.1:?cL f'P 'r't l'ftii .'i'a,". Of; IYi, LL.II-i f Id0iV�) Date:
C is ){` iizi01ii Ui. �Vti � /1� .fiil/q/l. tUti, 1ii;iiEC:v'1' Oj r'fi �S: - WT
J'+ tltiS aclfl- allJn ttlt ..A/c ['rS142S1'ti '?1'.'CS i tiCC of ii'r'i ur hcT ,n1c:1wD;1 w ti`t t h '--iccfzicall;fir?;,-z _i
Lucatioll {Street C, ,:U11 her
Owner or TC11allt
owner's:Address
Is fills pCr2111t in C011j :nctitln with bui?L'llty pc! ull! Yes l_1 No Ul (Check Appro)Ante Boxi
Vurllwif.,` of 1lut?di21, Ak4\.t €.'tltitv MitlitYrl7.:iliill €3.
iLt :flit Il ,At{1 l{. _r sAt:i tt � 5%1:52`-•1(l �-�1
New Scrvice Amus ! iuits Overi)e:ici n;u. of.�?etcrs
T7 d,
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Loc-itiun and N2turc of Proposed Electrical Work:
'^ 1 i°'? t �il IIA it- -rtable
t_U!Ul u O 1 U 1s:�U. tN nt `A , :-
F ( I t ma ce rmi ect by a.,Irlsr:c.:�i n(
l No,of Recessed Fixtures tNlo.of C!'ii.-S€Is IJ.{I':iddicf I'aus No, of J.0{aI
�' ^_ ITransforluers KVA, i
;No. o((_igi:iiilu Uluilcls hNo. of fiat I-u!}s t;eneratais .1-,V, j
Above t^ iIt- {- io. 0 me aeilcy i`Smata
#;No. of Liglltiag Fixtures e4r111T11i11ia 171)1 1 €,i ; t I! i
- arnc.. grnti. Battery L,nits
itis• of Re-ceptacle Outleis No of Oil Burners jFJRE ALiUR.Nls lNo. of Zones
? {l'�a_ c}-lletectiol1 ar.:: i
iiici.of Switches �i�Io.at Gas�surners T. lit'laiir d Dc:•iccs
A o€at
No.of R2n;es {i'ig.of Air Cottti_ cons IN-ij. of Alerting Det-ices ?
1 i I'zeat PURI Q Number 1'Fons KNV 1�0_of Self Contained
{•\n. of Wnste Di5oosers ----...t.----- 1
lr- .�...___---- r 4 A:
T�ol .,,. itiJeiLCrtfi}if it?rT;ii� f i`Sl?`
� u. of Dish, as:l:r, I i:lrea Heati:l '';;i 1T 24Iu: